Mosquito feeding behavior and how it influences residual malaria transmission across Africa

Significance Malaria transmission persists even when mosquito control is used effectively. This “residual transmission” measures all forms of transmission that are beyond the reach of standard insecticidal nets and indoor residual spraying of insecticides when used optimally. The epidemiological importance of the time of day mosquitoes bite and how much this contributes to residual transmission is unclear. The scale of the problem must be understood to demonstrate the need for outdoor vector control tools. An additional 10.6 million clinical cases of malaria are predicted annually given the 10% higher level of outdoor biting observed here. Mosquito species and behavior data together with people’s resting and sleeping patterns are needed to fully measure indoor intervention efficacy and accurately quantify residual transmission. The antimalarial efficacy of the most important vector control interventions—long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS)—primarily protect against mosquitoes’ biting people when they are in bed and indoors. Mosquito bites taken outside of these times contribute to residual transmission which determines the maximum effectiveness of current malaria prevention. The likelihood mosquitoes feed outside the time of day when LLINs and IRS can protect people is poorly understood, and the proportion of bites received outdoors may be higher after prolonged vector control. A systematic review of mosquito and human behavior is used to quantify and estimate the public health impact of outdoor biting across Africa. On average 79% of bites by the major malaria vectors occur during the time when people are in bed. This estimate is substantially lower than previous predictions, with results suggesting a nearly 10% lower proportion of bites taken at the time when people are beneath LLINs since the year 2000. Across Africa, this higher outdoor transmission is predicted to result in an estimated 10.6 million additional malaria cases annually if universal LLIN and IRS coverage was achieved. Higher outdoor biting diminishes the cases of malaria averted by vector control. This reduction in LLIN effectiveness appears to be exacerbated in areas where mosquito populations are resistant to insecticides used in bed nets, but no association was found between physiological resistance and outdoor biting. Substantial spatial heterogeneity in mosquito biting behavior between communities could contribute to differences in effectiveness of malaria control across Africa.